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Neurocritical Care Keaton S. Smetana, Pharm.D., MBA, FNCS, FCCM OhioHealth Riverside Methodist Hospital Columbus, Ohio Casey C. May, Pharm.D., FNCS, BCCCP The Ohio State University College of Pharmacy…

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Neurocritical Care Neurocritical Care Keaton S. Smetana, Pharm.D., MBA, FNCS, FCCM OhioHealth Riverside Methodist Hospital Columbus, Ohio Casey C. May, Pharm.D., FNCS, BCCCP The Ohio State University…

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Learning Objectives 3 min

Neurocritical Care Learning Objectives 1. Identify pertinent pathophysiologic and laboratory changes that acutely occur after neurologic injuries and require therapeutic intervention. 2. Describe…

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Neurocritical Care 3. A 25-year-old man is admitted after a two-story fall from a ladder. The initial computed tomography (CT) scan of his brain reveals a large right tempo- ral subdural hematoma,…

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Neurocritical Care beats/minute, respiratory rate 18 breaths/minute, Sao2 99%, and central venous pressure 5 mm Hg. Her most recent transcranial Doppler velocities are mean middle cerebral artery 1…

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Exam Content Outline 1 min

Neurocritical Care BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1: Critical C…

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Data Tables 2 min

Neurocritical Care I.  HYPONATREMIA A. Epidemiology: Hyponatremia (serum sodium less than 135 mEq/L) is common in patients with a neurologic injury (12%–43%). The most common form of hyponatremia in…

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Data Tables 2 min

Neurocritical Care Table 2. Hyponatremia Clinical Symptoms by Severity of Hyponatremia Serum Sodium <120 mEq/L Serum Sodium 120–130 mEq/L Serum Sodium 130–135 mEq/L • Headache • Restlessness •…

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Data Tables 3 min

Neurocritical Care Fluid Restriction PO Sodium IV Sodium Demeclocycline Vasopressin (V)-Antagonists Dose < 1500 mL/day 4–16 g/day (1 g = 17 mEq of Na) 0.9%–3% at 0.5–1.5 mL/ kg/hr 300 mg every 12…

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Neurocritical Care 4. Fludrocortisone 0.1–0.4 mg/day in divided doses may help reduce sodium loss in CSWS (Misra 2018; Lee 2008). a. An adverse effect of fludrocortisone is hypokalemia: Consider po…

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Neurocritical Care C. Typical Causes 1. Consideration of iatrogenic hypernatremia 2. Diabetes insipidus a. Decreased secretion of ADH or vasopressin results in decreased retention of water at the…

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Neurocritical Care E. Diagnosis/Pathophysiology – Diagnostic tests 1. Laboratory tests often show electrolyte abnormalities (particularly sodium, magnesium, and phosphorus), and serum lactate may b…

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Neurocritical Care 2. Second-line therapy (urgent): Initiate an anticonvulsant after benzodiazepine therapy if seizures persist or if a maintenance therapy needs to be initiated to prevent future se…

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Neurocritical Care I. Monitoring 1. Continuous EEG monitoring is necessary for status epilepticus and RSE. 2. Proactively monitor serum concentrations for agents such as (fos)phenytoin and valproic…

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Neurocritical Care Antiepileptic Drug Dosing Common Adverse Effects Considerations Pentobarbital 10 mg/kg (typically over 15–30 min, depending on blood pressure); typically need additional 5 to…

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Neurocritical Care IV.  CENTRAL NERVOUS SYSTEM INFECTION: INTRAVENTRICULAR ANTIBIOTIC ADMINISTRATION A. Case Selection 1. Recommended in adult patients with cerebral spinal fluid (CSF) shunt or ven…

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Neurocritical Care V.  INTRACRANIAL PRESSURE TREATMENT A. General Concepts 1. Elevated ICP decreases tissue perfusion and tissue oxygenation and worsens neurologic outcome. 2. Monro-Kellie doctrine…

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Data Tables 3 min

Neurocritical Care Mannitol Hypertonic Saline Typical dose 0.5–1 g/kg over 15 min (0.2-micron filter) Up to 1.6 g/kg if acute herniation 3%: 2.5–5 mL/kg over 15 min 7.5%: 1–2 mL/kg over 15 min 23.4%:…

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Neurocritical Care c. In contrast to midazolam, propofol is advantageous because of its short half-life and relative lack of residual sedative effects. 2. Benzodiazepines a. Not preferred because…

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Neurocritical Care b. Burst suppression on continuous EEG (target usually is 2–5 bursts/minute) is a surrogate end point for need of additional pentobarbital doses. c. A bolus dose is required conc…

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Neurocritical Care 1. Seizure prophylaxis a. Recommended as an option for prevention of early posttraumatic seizures (first 7 days after event) b. Phenytoin/fosphenytoin is the most commonly recomm…

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Neurocritical Care c. Potential for coagulopathy d. Need for mechanical ventilation 2. Almost all patients with a severe TBI should receive prophylaxis for stress-related mucosal bleeding (MacLare…

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Neurocritical Care e. Hypothermia during TBI may also reduce the induction of hepatic metabolism/cause metabolic rate of medications to be less than baseline. 3. Augmented renal clearance a. Incre…

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Neurocritical Care Table 9. Preventive and Abortive Therapies for Paroxysmal Sympathetic Hyperactivity Preventive Therapies Abortive Therapies Baclofen IT (titrated according to patient response) Brom…

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Data Tables 4 min

Neurocritical Care 4. Unknown (36.1%) 5. Other (2.6%) D. Treatment Considerations (2019;50:e344-418) 1. 1. Thrombolysis a. Alteplase 0.9 mg/kg (maximum 90 mg) within 4.5 hours of symptom onset; 1…

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Neurocritical Care b. Reduce blood pressure cautiously to avoid hypotension or underperfusion of infarcted area (less than 15% blood pressure lowering). c. Resumption of home blood pressure medicat…

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Neurocritical Care VIII.  INTRACEREBRAL HEMORRHAGE A. Epidemiology. Around 50,000 cases in the United States annually 1. Diagnosis/pathogenesis a. Neurologic examination b. Vital signs c. NIH Str…

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Data Tables 4 min

Neurocritical Care Table 11. Anticoagulant Reversal Options Anticoagulant Reversal Agent and Dose Adverse Effects Warfarin 4F-PCC [INR < 4 (25 units/kg, max 2500 units), INR 4–6 (35 units/kg, max 350…

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Neurocritical Care f. Evidence also suggests that blood pressure fluctuations in the first 4–6 hours post-ICH are associated with poor functional outcomes (Stroke 2018;49:348-54). g. Large, interna…

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Neurocritical Care B. Diagnosis/Pathogenesis 1. Serial neurologic examination 2. Vital signs 3. NIH Stroke Scale and/or GCS score Table 13. SAH Severity Scale Scores Score Range Comments Hunt and…

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Neurocritical Care ii. Endothelin activation iii. Liberation of hemoglobin results in the scavenging of nitric oxide. d. Vasospasm is one of the main factors resulting in death or disability after…

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Neurocritical Care iv. Abrupt withdrawal of statins in patients who were taking statins before SAH may result in a withdrawal effect and increase the risk of vasospasm. d. Other studied agents i.…

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Neurocritical Care 6. Role of nicotine replacement therapy (NRT) – Smoking is a common risk factor for developing cerebral aneurysms. a. Nicotine administration to naive users causes vasoconstricti…

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Neurocritical Care a. Combination with mechanical thrombectomy b. Rescue therapy in patients having received intravenous thrombolytic c. Large hemispheric infarction i. Dose is not well defined. i…

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Neurocritical Care Patient Case Questions 7 and 8 pertain to the following case. A 52-year-old woman is admitted to your ICU after a single-vehicle crash. She has many orthopedic injuries to her lowe…

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Neurocritical Care iv. ASIA D: Incomplete, motor function is preserved below the neurological level of injury, and at least half the key muscles below the injury level have a muscle grade of 3 or mo…

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Neurocritical Care 2. Low-molecular-weight heparins are the drugs of choice for prophylaxis and should be initiated within 36 hours post-injury. 3. Duration of prophylaxis is typically about 8 week…

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Neurocritical Care B. Diagnosis/Pathogenesis – Diagnostic tests 1. Contrast-enhanced MRI is the most common test. 2. Biopsy is often necessary to reveal the specific histology. C. Clinical Impact…

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Neurocritical Care b. Microcirculatory ischemia c. Protein catabolism in severe critical illness/immobility may cause muscle wasting. 2. Often associated with: a. Sepsis b. Multiorgan dysfunction…

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Neurocritical Care 4. Respiratory failure 5. Autonomic dysfunction resulting in arrhythmia, hypertension, hypotension 6. Neuropathic pain E. Treatment Considerations (N Engl J Med 1992;326:1123-9)…

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Data Tables 2 min

Neurocritical Care C. Treatment Considerations 1. Intravenous immunoglobulin 0.4 g/kg/day × 3–5 days or plasmapheresis 20–25 mL/kg plasma × 5 exchanges every other day × 10 days a. Similarly effec…

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Data Tables 2 min

Neurocritical Care Table 16. Distinguishing Features between Serotonin Syndrome and Neuroleptic Malignant Syndrome. Feature Serotonin Syndrome Neuroleptic Malignant Syndrome Trigger drug Drug with ser…

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Neurocritical Care iv. Cannot recalibrate the catheter, experience “zero drift” in ICP readings after prolonged use. May not be entirely accurate for duration of use d. Brain tissue oxygen monitor…

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Neurocritical Care XVIII.  IMPACT OF SOCIAL DETERMINANTS OF HEALTH (SDOH) A. SDOH are conditions in the places where people live, learn, work, and play that affect health risks and outcomes. B. Dis…

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Neurocritical Care REFERENCES Achinger SG, Ayus JC. Treatment of hypona- tremic encephalopathy in the critically ill.  Crit Care Med. 2017;45(10):1762-1771. https://doi.org/10.1097/ ccm.00000000000…

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Neurocritical Care edition.  Neurosurgery. 2017;80(1):6-15. https://doi. org/10.1227/neu.0000000000001432 Chamberlain JM, Kapur J, Shinnar S, et al. Efficacy of levetiracetam, fosphenytoin, and va…

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Neurocritical Care Hirschl M. Erfahrungsbericht über die Magenschutztherapie bei hochdosierter Kortikosteroidbehandlung von Hirntumorpatienten [Report of experience with stomach-protect…

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Neurocritical Care open-label, registry-linked, randomised, controlled, non-inferiority trial.  Lancet. 2022;400(10347):161-169. https://doi.org/10.1016/s0140-6736(22)01054-6 Mikkelsen N, Damkier P…

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Neurocritical Care Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute isch- emic stroke: 2019 update to the 2018 guidelines for the early managem…

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Neurocritical Care Temkin NR, Dikmen SS, Anderson GD, et al. Valproate therapy for prevention of posttraumatic seizures: a ran- domized trial. J Neurosurg. 1999;91(4):593-600. https:// doi.org/10.317…

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Answers & Explanations 4 min

Neurocritical Care ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: C Answer C is correct because midazolam (together with lorazepam) is recommended by the status epilepticus guidelines. Answer…

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Self-Assessment 4 min

Neurocritical Care ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: B Answer B is correct because sodium supplementation is effective for treating hypovolemic and euvolemic hyponatr…

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Neurocritical Care which is undesirable in a patient with ongoing cerebral vasospasm. Answer D is incorrect; although a blood transfusion might theoretically increase oxygen-carry- ing capacity to t…

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